A preschool-aged child who is being tested for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding
provides the clearest indication to the nurse that the child is experiencing a reaction to toxins that are created by Streptococcal bacteria.
Flushed, peeling skin
Red bumps across chest
White coating on tongue
High, protracted fever
The Correct Answer is A
The correct answer is A. Flushed, peeling skin
Choice A reason: Flushed, peeling skin is a classic sign of scarlet fever, which is a condition that can arise from Streptococcal pharyngitis. Scarlet fever is characterized by a red rash that can cover most of the body and may lead to the skin peeling. This symptom is a direct reaction to the toxins produced by the Streptococcal bacteria.
Choice B reason: Red bumps across the chest could be indicative of many conditions and are not specifically characteristic of the reaction to toxins produced by Streptococcal bacteria. While a rash is common in scarlet fever, it typically starts on the face or neck and spreads to the rest of the body, rather than presenting as isolated red bumps.
Choice C reason: A white coating on the tongue, often referred to as “strawberry tongue,” is indeed associated with scarlet fever. However, it is not the clearest indication of a reaction to the toxins. The white coating usually precedes the strawberry-like appearance, where the tongue becomes red and bumpy.
Choice D reason: While a high fever is a symptom of scarlet fever, it is not specific to the reaction to toxins from Streptococcal bacteria, as many infections can cause high fevers. The term “protracted” suggests a prolonged fever, which could be seen in various conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Notifying the emergency response team of the client's seizure is not a necessary action for the nurse, as the seizure has already stopped and there is no immediate threat to the client's life. This is a distractor choice.
Choice B: Keeping orienting the client to time and place until he is less confused is an appropriate action for the nurse, as this can help restore the client's cognitive function and reduce his anxiety after a seizure. Therefore, this is the correct choice.
Choice C: Explaining the postictal state that usually follows seizures is not a priority action for the nurse, as this can be done later when the client is more alert and receptive. This is another distractor choice.
Choice D: Asking the wife to wait outside the room until the nurse can talk with her is not a considerate action for the nurse, as this can increase her stress and worry about her husband's condition. This is a contraindicated choice.
Correct Answer is C
Explanation
Choice A reason: Measuring abdominal girth is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be useful for monitoring fluid status and abdominal distension.
Choice B reason: Assessing perineal area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be important for maintaining hygiene and preventing infection.
Choice D reason: Palpating flank area is not a specific assessment for a client with a suprapubic catheter, which is a tube inserted through the lower abdomen into the bladder to drain urine. However, it may be helpful for detecting kidney tenderness or enlargement.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today